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3 Key Information Deadliest Ebola outbreak in history with approximately 29,000 reported cases and 11,000 fatalities between December 2013 and April 2016 Triggered an unparalleled global response as the Ebola virus became a global threat In March 2015, Liberia achieved Ebola-free status. Sierra Leone and Guinea achieved Ebola-free status shortly thereafter, although cases continued to be reported until as recent as May 2016 There is no proven vaccine for Ebola. Improved WASH practices, community engagement, and social mobilization continue to be essential to preventing a resurgence

6 Before Ebola: Focus on Sanitation Sanitation coverage as low as 12-15%

7 Early CLTS Challenges CLTS introduced in 2010; little progress until 2013 No government structures at county & district level for CLTS coordination, implementation, sustainability Lack of adequate monitoring of community progress Lesson: Intensive sustained engagement is key to CLTS success

14 Key Lessons CLTS can be more than just a tool for sanitation promotion. Momentum can be harnessed to promote other community health and development objectives. Involving Natural Leaders (NL) and CLTS communities in other public health programming related to disease surveillance improves the dissemination of health messages (polio/measles vaccination campaigns, cholera prevention, EVD awareness, etc.) from the Ministry level down to the communities. CLTS and NL engagement in other health-related activities (surveillance, social mobilization, vaccination campaigns, maternal and child health, etc.) has raised government awareness of the need for more targeted support to the community-level health system and demonstrates a more low-cost, sustainable option.

17 Ebola: Fighting the Unknown First Ebola outbreak affecting several countries (3 large scale + sporadic cases in others) World Health Organization declared EBOLA an international public health emergency 8/08/2014, UNICEF corporate L3 30/08/2014 No guidelines for WASH response in large scale Ebola A lot of fear to intervene in such context/media frenzy 17

21 Developing the Appropriate WASH Package WASH in communities: Door to Door promotion: preventive behaviour (no touch policies + burial) + handwashing soap Mass media campaign on all protective behaviors Stay at home campaign distribution of soap + messages WASH in school: Development and dissemination of the Safe school protocol - Feb 2015 (IPC, handwashing) Distribution of supplies in all schools Creation and dissemination of IEC material for children Monitoring of safe school protocols by the government Early referral/ no touch policy key behaviours to stopping disease transmission: Handwashing only a contributing factor

22 Handwashing Debate What should we promote, where and who will do it? 1. Should we promote handwashing knowing that it is not the key protective behaviour or concentrate on the no touch policy, burial might give a wrong sense of security? 2. Handwashing with Chlorine or Soap: effectiveness? difficult for people to perform? availability of supply? risk of soap being perceived as not effective for the future! 3. Who should do handwashing promotion? WASH NGO trained Social mobilization actors scaling up? 4. How should we do the promotion with the non touch policy, no possibility of community meeting?

23 Handwashing Activities in Sierra Leone Handwashing in Ebola and health is a component of IPC: medical personal will be in charge - use of chlorine Mandatory Handwashing in public place: official building, check point, supermarket mostly with chlorine Mandatory 23

24 Handwashing Activities in Sierra Leone Handwashing with soap in communities should be promoted Using all personal trained (door to door) and available medias Handwashing prevention/soap distribution can be use as entry point/reminder of the situation to introduce others behaviours Handwashing with soap in school as part of safe school protocol with provision of supplies creation of new norms 24

26 Impact of Handwashing Promotion Improved knowledge and practice of Handwashing with soap/chlorine During the outbreak a new social norms was created: washing hand with soap or chlorine before entering public place (school) The contribution of Handwashing in ending the outbreak is unknown? Case management: early referral and containment are key to reducing transmission Evidence that community empowerment (ODF communities) is a protective factors (Liberia study) 26

27 Lesson learned from EBOLA Production of timely guideline is paramount for emerging context (UNICEF, WHO) - the Ebola framework can be reused Importance of coordination of efforts to avoid confusion of message (IPC, social mobilisation, wash cluster/sector) Building on experience of local actors especially community development actors (eg CLTS, WinS) Knowledge management should be improved (separate team?) to build evidence for the future 27

28 Open Question? In the future, what should be promoted handwashing with soap or chlorine (HTH)/NADCC? Does it depend on the type of disease and location (household, public space)? How do we sustain the handwashing social norms create during the outbreak? How do we monitor it? Coordination of Hygiene promotion sub cluster (WASH) with the discussed social mobilisation cluster? 28

34 Improving Hand Hygiene During Ebola Response Expensive Not available Loss Need WASH for clean and safe water

35 Improving Hand Hygiene During Ebola Response Entrance of a hospital in Guinea

36 Improving Environmental Cleaning An operating table in a hospital in Guinea A cart in an operating room in a hospital in Guinea Shelves of a cart in an operating room in a hospital in Guinea

37 Improving Sharps Safety A needle sticking on an IV bag in a hospital in Guinea Safety boxes used in a hospital in Guinea

38 Improving Waste Management West storage area in a hospital in Guinea

39 Improving Disinfection of Medical Equipment A bucket used for disinfecting medical equipment in a hospital in Guinea

40 Key Take Home Messages WASH is the basic need for IPC in healthcare settings For sustainability, national policy and strategic plan for IPC must include a section on WASH There should be collaboration between WASH and IPC at all levels International (e.g., WHO, CDC, UNICEF) National (e.g., IPC Working Group should include representatives from WASH) Facility (IPC and WASH Working Groups should be integrated)

41 Key takeaways for the WASH & SBC sectors CLTS engagement in other health-related activities has raised government awareness of the need for more targeted support to the community-level health system and demonstrates a more low-cost, sustainable option CLTS can be more than just a tool for sanitation promotion and momentum can be harnessed to promote other community health and development objectives Technical guidance and evidence-based knowledge must be provided at the RO/HQ level Knowledge and Information Management must be supported and cross-sectoral monitoring should be clearly defined between sectors/clusters to reduce gaps or overlaps between IPC and WASH programs IPC programs within healthcare structures must integrate improved WASH practices at all levels and WASH is critical for IPC in healthcare settings For sustainability, national policy and strategic plans for IPC must include a section on WASH

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